OPINION | UK maternity scandal and the danger of dogma

A five-year investigation into the avoidable deaths of 201 babies and nine mothers at a UK hospital — described by one British newspaper as “the worst maternity scandal in history” — has ignited a debate over healthcare that has ramifications outside Britain. 

The official report by Donna Ockenden, a senior midwife and businesswoman, revealed this week that the health of expectant mothers and their babies was sacrificed to dogma.

Former secretary of state Jeremy Hunt, who ordered the inquiry five years ago, says “the natural birth ideology ... proved to be absolutely catastrophic at Shrewsbury and Telford”. That hospital’s refusal to admit initial mistakes was another main factor. It does not continue to stand by those policies.

At Shrewsbury and Telford hospital trust, Debbie Greenway was one victim. When she asked for a caesarean section — her twins had with difficulty been conceived by IVF — the doctor repeatedly dismissed her request: “We’ve got the lowest caesarean rates in the country and we are proud of it and we plan to keep it that way.”

After an extended period of labour, Greenway lost one of her babies and was told it was a highly unusual occurrence. It wasn’t. 

Greenway’s natural birth followed repeated doses of syntocinon, a drug used to bring on contractions after her extended labour. An earlier caesarean would likely have saved the life of the baby she had already named John.

Many other mothers-to-be were given similar brush-offs at Shrewsbury. No whistle-blower at the hospital alerted the authorities when death rates rose and babies were permanently damaged by unnecessary forceps deliveries. It took a campaign by a few brave families to prompt a health minister to order an official inquiry after years of stonewalling.

Ockenden reported that “a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth”.

The scandal began with well-intentioned but unscientific thinking. In the 1980s, concerns grew that childbirth was being over-medicalised, especially by arrogant male doctors. Health lobbies began to advocate for fewer interventions. This development, it could be argued, was a course correction. 

But in 1985, the World Health Organisation briefly threw its authority behind natural birth, declaring that health services should limit caesareans to 10-15% of all childbirths. By 2007 in Britain, that preference began to harden into dogma — despite the WHO’s swift withdrawal of its ruling. The Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists, and the National Childbirth Trust set a target of 60% “normal” childbirths in UK hospitals.

Soon it became fashionable for natural birth propagandists to sneer at successful women for being “too posh to push”, by electing for a caesarean. There was also pressure by some midwives on expectant mothers to give birth without the pain relief provided by epidural injections.

This echoes a larger problem in healthcare of women’s pain being taken less seriously. Caesareans are not cheap, so hospital managers had a perverse incentive to restrict operations too — just as their predecessors in the NHS in previous decades had saved money by ejecting mental patients from their wards. (C-section rates vary across the developed world.)

Shrewsbury and Telford was at the vanguard of this movement. Expectant mothers were denied the right to opt for a caesarean section, and only a senior consultant was allowed to authorise the procedure. By 2002, the trust had the lowest C-section rate in the country — eight to 12% lower than the 30% national average. That year David Redford, an obstetrician at the trust, boasted to a House of Commons committee, “We have below intervention rates, and once that is known, we attract both midwives and obstetricians that like to practise in that way.” 

Mortality rates in the hospital maternity services rose more than 10% above the national average. Yet according to Ockenden, two clinical commissioning groups in 2013 gave the trust a clean bill of health. That report stated that “there is a robust approach to risk management, clinical governance, and learning from incidents. It is clear that Shropshire has a maternity service to be proud of and that the model of service provision is safe and robust.” 

Good hospitals measure, manage and hold clinicians to account through reviews and best-practice benchmarking. But what if higher medical authority subscribes to health fads too, wilfully ignoring the evidence of failure?

Unfortunately, the natural birth movement is not an isolated case of unscientific thinking in the medical profession. Homeopathy, a “natural treatment” based on the use of highly diluted substances, which practitioners claim can cause the body to heal itself, was funded until recently by the NHS.

In 2010, a House of Commons report declared that homeopathic remedies perform no better than placebos (dummy treatments), but it took a further seven years for the NHS to drop these useless (but fortunately harmless) treatments, which were promoted by the likes of Prince Charles and other establishment figures.       

The Royal College of Midwives ended its campaign to promote natural birth in 2017. Yet it was only last month that the NHS announced that it would no longer place a limit on the number of caesarean sections it performs. The country’s most senior midwife, Jacqueline Dunkley-Bent, instructed health workers to “stop using total caesarean section rates as a means of performance management” because it was unsafe. 

Despite the Ockenden report, three other hospital trusts continue to promote vaginal births over C-sections. An advertisement for Keighley Yorkshire Trust says “successful candidates will be able to demonstrate their commitment ... promoting the normal birth pathway and reducing interventions”.

The best health-safeguarding systems in the world won’t work if there are perverse incentives — such as misguided C-section targets and financial rewards — to override them. More maternity units across the UK are now being investigated by the department of health. Fear the worst.

Martin Ivens was editor of the Sunday Times from 2013 to 2020 and was formerly its chief political commentator. He is a director of the Times Newspapers board.

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